Community participation in the collaborative governance of primary health care facilities, Uasin Gishu County, Kenya

Introduction: Community participation in the governance of health services is an important component in engaging stakeholders (patients, public and partners) in decision-making and related activities in health care. Community participation is assumed to contribute to quality improvement and goal attainment but remains elusive. We examined the implementation of community participation, through collaborative governance in primary health care facilities in Uasin Gishu County, Western Kenya, under the policy of devolved governance of 2013. Methods: Utilizing a multiple case study methodology, five primary health care facilities were purposively selected. Study participants were individuals involved in the collaborative governance of primary health care facilities (from health service providers and community members), including in decision-making, management, oversight, service provision and problem solving. Data were collected through document review, key informant interviews and observations undertaken from 2017 to 2018. Audio recording, notetaking and a reflective journal aided data collection. Data were transcribed, cleaned, coded and analysed iteratively into emerging themes using a governance attributes framework. Findings: A total of 60 participants representing individual service providers and community members participated in interviews and observations. The minutes of all meetings of five primary health care facilities were reviewed for three years (2014–2016) and eight health facility committee meetings were observed. Findings indicate that in some cases, structures for collaborative community engagement exist but functioning is ineffective for a number of reasons. Health facility committee meetings were most frequent when there were project funds, with discussions focusing mainly on construction projects as opposed to the day-to-day functioning of the facility. Committee members with the strongest influence and power had political connections or were retired government workers. There were no formal mechanisms for stakeholder forums and how these worked were unclear. Drug stock outs, funding delays and unclear operational guidelines affected collaborative governance performance. Conclusion: Implementing collaborative governance effectively requires that the scope of focus for collaboration include both specific projects and the routine functioning of the primary health care facility by the health facility committee. In the study area, structures are required to manage effective stakeholder engagement.